Algover's shock index is which of the following?

A. PR/SBP.

B. SBP/CVP.

C. SBP/ PR.

D. CVP/CBV.

E. CBV/ CVP.

PR = pulse rate. SBP = systolic blood pressure. CVP = central venous pressure. CBV = circulating blood volume.

Choose the correct answer.

5. Infusion therapy of degree III anaphylactic shock consists in which of the following:

1. Administration of epinephrine.

2. Corticosteroids (prednisone, decadron, hydrocortisone).

3. H₂ receptor antagonists (dimedrol, pypolphen, suprastin).

4. Calcium preparation (calcium chloride, calcium gluconate).

5. Narcotic agents (fentanyl, morphine).

Choose the right combination of answers:

A. 1, 2, 3, 4, 5. B. 1, 2, 3, 5. C. 1, 2, 3, 4. D. 2, 3, 4, 5. E. 1, 3, 5.

6. The signs of torpid phase of degree II traumatic shock include the following:

1. Agitation.

2. Adynamia.

3. Hypertension.

4. Hypotension.

5. Tachycardia.

Choose the right combination of answers:

A. 1, 3, 5. B. 2, 4. C. 2, 4, 5. D. 2, 3, 4, 5. E. 1, 4, 5.

7. The parameters that dictate the volume of infusion therapy in hypovolaemic shock are as follows:

1. ECG.

2. BP and pulse rate.

3. CVP.

4. Haematocrit.

5. Complete blood count.

Choose the right combination of answers:

A. 1, 2, 5. B. 1, 2, 3. C. 2, 3, 4. D. 1, 5. E. 1, 2, 3, 4, 5.

8. Treatment of collapse include the following measures:

1. Trendelenburg's position of the patient.

2. Injection of corticosteroids.

3. Inhalation of ammonia water.

4. Injection of analeptics.

5. Infusion of macromolecular dextrans.

Choose the right combination of answers:

A. 1, 2. B. 2, 3. C. 1, 3, 5. D. 1, 3, 4. E. 1, 2, 3, 4, 5.

9. The adverse effects of mask general anaesthesia include the following:

1. High toxicity.

2. An increase in anatomic dead space.

3. An increase in physiologic dead space.

4. A risk of regurgitation and aspiration of the gastric contents.

5. A risk of overdose.

Choose the right combination of answers:

A. 1, 2, 3, 4, 5. B. 1, 4, 5. C. 2, 4. D. 1, 5. E. 4, 3.

10. The advantages of endotracheal general anaesthesia include the following:

1. Reliable prevention of the gastric contents aspiration.

2. A decrease in anatomic dead space.

3. Reliable muscular relaxation.

4. A low risk of overdose of anaesthetics.

5. Reliable prevention of pneumonia.

Choose the right combination of answers:

A. 1, 2, 5. B. 3, 4, 5. C. 1, 2, 3. D. 1, 5. E. 1, 2, 3, 4, 5.

11. The agents used for general anaesthesia that may cause anaphylaxis include the following:

1. Barbiturates.

2. Ether.

3. Halothane.

4. Propanidid.

5. Ketamine.

Choose the correct answer.

12. Sudden cardiac arrest causes irreversible cortical lesions after which of the following periods:

A. 10 minutes.

B. 12 minutes.

C. 4-5 minutes.

D. 1-2 minutes.

Choose the correct answer.

13. The male patient suspected of having ileus is admitted to the surgical department after 3 days of recurrent vomiting, adynamia, and palpitations. The most significant metabolic problems that require correction preoperatively (pre-anaesthetically) are as follows:

1. Hypokalaemia, hypochloraemia.

2. Hyponatraemia, hypocalcaemia.

3. Hypoproteinaemia.

4. Hypovolaemia.

5. Anaemia.

Choose the right combination of answers:

A. 2, 3. B. 1, 2, 3. C. 4, 5. D. 1, 4. E. 1, 2, 3, 4, 5.

14. The signs of hypovolaemia due to pyloric stenosis or ileus include the following:

1. CVP (central venous pressure) < 4 mm H₂O.

2. CVP < 2 cm H₂O.

3. Tachycardia.

4. Hct > 45%.

5. Hct < 45%.

Choose the right combination of answers:

A. 1, 2, 3, 4, 5. B. 1, 3, 4. C. 1, 3, 5. D. 2, 3, 4. E. 2, 3, 5.

15. The measures to promote peripheral circulation include which of the following:

1. Administration of sympathomimetics (ephedrine, mezatone, norepinephrine).

2. Haemodilution to decrease blood viscosity.

3. Infusion of high molecular dextrans (polyglukin).

4. Infusion of low molecular dextrans (rheopolyglukin).

5. Blood transfusion.

Choose the right combination of answers:

A. 1, 2, 3, 4, 5. B. 2, 4. C. 2, 5. D. 1, 2. E. 3, 5.

16. The patient has combined trauma (craniocerebral and femoral fracture), II-III degree traumatic shock (BP 80/ 40 mm Hg, pulse - 120/minute). Intensive care prior to admission to hospital includes the following steps:

1. Blood transfusion.

2. Immobilization.

3. Nutritional support (polyglukin, rheopolyglukin, gelatinol).

4. Anaesthesia with non-narcotic analgesics.

5. Administration of vasopressors to increase BP.

Choose the right combination of answers:

A. 1, 2, 3, 4, 5. B. 1, 2, 4. C. 2, 3, 4. D. 2, 4, 5. E. 1, 4, 5.

Chapter IV. HAEMORRHAGE

Haemorrhage, or bleeding, is the escape of blood from the blood vessels as a result of an injury or defect in the permeability of the vascular walls. Blood loss is a life-threatening condition, which necessitates prompt treatment, as the life of the injured person invariably depends on how fast the doctor can deal with the problem.

In terms of the mechanism, haemorrhage divides into:

• mechanical (disruption or erosion of a vessel);

• neurotrophic (impaired permeability of vessels as a result of vascular wall pathology, which can be secondary to various diseases - scarlet fever, scurvy, haemophilia etc).

The following types of haemorrhage are identified:

1) haemorrhage per rexin (as a result of mechanical damage to the vessel - a tear or rupture);

2) haemorrhage per diabrosin results from erosion of blood vessels (by a tumour, in tissue necrosis and in infections);

3) haemorrhage per diapedesin due to a defect in the permeability of the vascular walls.

Bleeding can also be classified as arterial, arteriovenous, venous and capillary. Parenchymal bleeding is a capillary type of bleeding from an organ like the liver.

Bleeding can also be external (when blood oozes outside the body) and internal (when blood accumulates in an enclosed space of the body or in the cavity of a hollow organ). Moreover, it can be occult, when diagnosed only by means of specific methods of investigation.

Traumatic bleeding is classified as follows:

• primary (results from an injury to a vessel);

• secondary (occurs if a clot breaks away from the vessel because of a rise in blood pressure or as a result of vascular spasm, in which case it is referred to as early secondary bleeding). On the other hand, late secondary bleeding is due to clot dissolution secondary to pyogenic infection or erosion of the vascular wall.

ACUTE HAEMORRHAGE

Intractable bleeding is life-threatening due to development of shock. Its severity depends on the intensity, duration of bleeding and the volume of blood loss. A fast decrease (i.e. as much as 30%) in blood circulating volume can cause acute anaemia, hypoxia of the brain that can be fatal. When bleeding persists for a long period but in smaller amounts, there are only few circulatory changes, if at all, and the patient can live with as low as 20 g/l of haemoglobin. This is explained as follows. A reduction in blood circulating volume leads to a decrease in venous pressure and the heart ejection force which, in turn, stimulates adrenal secretion of catecholamines and, therefore, vascular spasm and a reduction in vascular volume; all these maintaining appropriate haemodynamics in a safe state.

The four degrees of blood loss are identified:

1) mild - a reduction in blood circulating volume of 10-12%, or 500-700 ml of blood;

2) moderate - a reduction in blood circulating volume of 15-20%, or 1, 000-1, 400 ml of blood;

3) severe - a reduction in blood circulating volume of 20-30%, or 1, 500-2, 000 ml of blood;

4) massive - a reduction in blood circulating volume of more than 30%, or more than 2, 000 ml of blood.

In severe blood loss the patient develops acidosis with subsequent marked destruction of the microcirculatory system and aggregation of red blood cells in the capillaries. Oliguria (i.e. a reduction in urine volume), which is initially of reflex in character, evolves to anuria (i.e. cessation of urine production) at the stage of decompensation, resulting from the insufficient renal perfusion.

Clinical picture comprises general and local signs. It is noteworthy that the extent of the general signs varies with the degree of haemorrhage. The signs include skin pallor, diaphoresis, facial cyanosis, weak and fast pulse, tachypnoea (periodic breathing, or Cheyne-Stokes phenomenon) in severe cases, as well as a decrease in venous and arterial blood pressure levels. The symptoms involve headache, dryness in the mouth and thirst, nausea, blurred vision and progressive malaise. In contrast, if the blood is being lost slowly, the symptoms and signs may not reflect the amount of the blood lost. It will be noted that the amount of blood loss be evaluated, as this will subsequently, after bleeding arrest, help choose the appropriate therapeutic strategy a reduction in blood circulating volume of 15-20%, or 1, 000-1, 400 ml of blood.

Laboratory investigations. Checking for levels of the red blood cells, haemoglobin and haematocrit should be done on admission and repeated afterwards. In severe bleeding, the results of the investigations mentioned may not serve as objective indicators of the degree of haemorrhage in the first few hours, since autohaemodilution occurs with time, reaching its maximum within 1¹/₂-2 days.

It is haematocrit and blood specific gravity which can be relied upon in judging about the interrelationship between the cellular components of blood and plasma.

The blood specific gravity of as much as 1, 057-1, 054, haemoglobin 65-62 g/l, haematocrit 44-40 suggest blood loss as high as 500 ml, while those of 1, 049-1, 044, 53-38 g/l, and 30-23, respectively, mean that the amount of the blood lost is above 1, 000 ml.

A progressive fall in venous blood pressure suggests that the heart is not receiving enough blood due to a reduction in blood circulating volume. It is measured either in the superior or inferior vena cava. This is performed with a catheter passing through the median cubital or long saphenous vein. The most factual method is whereby the amount of blood loss is checked by calculating the deficit in blood circulating volume and its components (i.e. circulating plasma volume, volume of cellular blood components, etc). The method consists in the introduction of specific indicators (Evans' blue, radioisotopes, etc.) into the vascular system. The concentration of the diluted indicator in the blood helps determine the plasma volume; using the standard table and the haematocrit value allows for the calculation of blood circulating volume and globular volume. The normal values of blood circulating volume and its components are found from the standard table based on the patient's body weight and sex. The difference between the normal and the actual values is used to estimate the deficit in blood circulating volume, circulating plasma volume and the globular volume, i.e. the amount of blood lost.

Special diagnostic methods. If internal bleeding is suspected, diagnostic puncture should be performed (thoracocentesis in haemothorax, laparocentesis in haemoperitoneum, arthrocentesis in haemarthrosis, puncture of the posterior vaginal fornix in ruptured ectopic gestation or ovarian cyst). If indicated, X-ray, ultrasound scanning and computerised tomography can also be used. Endoscopic methods include gastroscopy, rectoscopy, cystoscopy and arthroscopy.

It will be noted that clinical symptoms and signs as well as the laboratory findings are used to evaluate the severity of blood loss.

Treatment. The treatment of haemorrhage must be started with maximum swiftness, since a prompt initiation of therapy can prevent the haemorrhagic shock.

The management of severe bleeding has to be started with infusions of blood substitutes before blood grouping and cross-matching. It is important because the human body's tolerance of the plasma loss and hence a reduction in the circulating blood volume is lower than that of the fall in red blood cell count. Albumin, protein and polyglucin are readily held in blood vessels; crystalloids can be used if necessary, but they tend to leave the vascular system rather early. Low-molecular dextran (rheopolyglukin) replenishes the intravascular fluid volume, which improves the microcirculation and rheologic properties of blood. Blood transfusion should be considered whenever haemoglobin and haematocrit levels fall as low as 80 g/l and 30, respectively.

In severe acute bleeding, blood transfusion should be started by the fast flow method through one, two or even three veins, while slow infusion can be justifiable only after the systolic blood pressure has at least risen to as high as 80 mm Hg. Acidosis is corrected by giving sodium bicarbonate, trisamin and lactasol (see Chapter IV). The drugs that increase the vascular tone, or vasopressors, should be avoided until the volume of circulating blood has been fully restored, since they are likely to aggravate hypoxia. Alternatively, steroids act to enhance myocardial contractility and counteract peripheral vascular spasm. Oxygen therapy should also be considered; especially effective is hyperbaric oxygenation, which is used after bleeding has stopped.

External bleeding. External bleeding is the major sign of injury. The colour of the escaping blood depends on the type of the vessel affected: it is bright red in arterial bleeding and dark red in venous haemorrhage. It is noteworthy that the lethal bleeding within a few minutes after injury may result not only from a damage to the aorta but also from that to the femoral or axillary arteries or even larger veins. Injury to the major cervical or thoracic vessels can lead to a very serious complication - air embolism. This occurs as a result of air entering the neck veins through the laceration, which subsequently reaches the right cardiac chambers to finally obstruct the branches of the pulmonary artery.

Internal bleeding. This is usually due to traumatic injuries or a pathology of or around the vessel. Making the diagnosis of internal bleeding is more difficult than that of external. The clinical picture incorporates the general signs associated with haemorrhage and localones that vary with the location of the bleeding vessel.

In acute anaemia (e.g. due to a ruptured ectopic pregnancy or ruptured spleen with subcapsular haematoma) the clinical picture is as follows:

• extreme pallor of the skin and visible mucous membranes;

• blurred vision;

• dizziness;

• thirst;

• drowsiness;

• fainting (in severe cases);

• tachycardia (120-140 beats per minute);

• hypotension.

If the bleeding is slow or mild, the signs develop gradually.

When blood escapes into a hollow organ and is discharged via a natural opening outside, the origin of the bleeding (e.g. the blood oozing out of the mouth can be a result of bleeding from the lung, trachea, pharynx, oesophagus, stomach or duodenum) is always difficult to elucidate. The colour and type of blood is, therefore, of great importance:

• foamy bright red blood (in bleeding from the lung);

• ground coffee-like vomitus (in gastric or duodenal haemorrhage);

• melaena, or black stools ( in bleeding from the upper GIT);

• bright red blood coming from the rectum (in bleeding from the sigmoid or rectum);

• haematuria (in bleeding from the kidney or urinary tract).

To locate the bleeding vessel, specific diagnostic procedures are to be performed: passing a probe into the stomach; digital per rectum examination; endoscopic methods like bronchoscopy in diseases of the lung, oesophagogastroduodeno-, rectosigmoido-, and colonoscopies for gastrointestinal haemorrhages, cystoscopy for diseases of the urinary tract, ultrasound, X-ray are applicable. They are most important for occult bleeding which is not heavy or presents atypically. A radioisotope method can also be used to diagnose internal bleeding. The gist of the method is that a radioactive isotope (normally a colloid solution of gold) injected intravenously accumulates, together with the haemorrhaged blood, in a tissue, cavity or hollow organ. An increase in radioactivity at the area damaged is found during radiometry.

The diagnosis of bleeding into an entrapped body cavity (the cranium, spinal canal, thoracic and abdominal cavities, pericardium and synovial space) tends to be the most complicated. The specific signs of fluid accumulation in a cavity and the general signs of bleeding are indicative of various types of internal bleeding:

Haemoperitoneum, or accumulation of blood in the abdominal cavity, is associated with

• lacerations and blunt injuries to the parenchymal organs (the liver, spleen) or mesenteric vessels;

• rupture of an ectopic pregnancy or an ovarian cyst, loosening of the ligature placed on a bleeding vessel when it loosens or unties post-operatively, etc.

The local signs of the abdominal bleeding may be as follows:

• restricted abdominal breathing;

• abdominal pain;

• slight rigidity of the abdominal wall;

• mild peritoneal tenderness (Blumberg's sign);

• dull tympanitic sound over the areas of blood accumulation (when about 1, 000 ml are accumulated);

• bulging the posterior fornix in women on vaginal examination.

The patients suspected of having haemoperitoneum should be closely monitored (particularly in terms of their haemoglobin and haematocrit values) are monitored in dynamics. A progressive fall in these makes the diagnosis of haemoperitoneum most likely. It will be noted, however, that if bleeding is secondary to the rupture or tear of a hollow organ, the signs of haemoperitoneum can be masked by those of the impending peritonitis. To verify the diagnosis, laparocentesis using a «balloon» catheter, peritoneal lavage as well as laparoscopy play a very important role. As soon as the diagnosis is confirmed, the patient must be immediately laparotomised with exploration of the abdominal cavity and stoppage of bleeding.

Haemothorax, or accumulation of blood in the pleural cavity, results from

• injuries to the chest and lung;

• surgical manipulations;

• diseases of the lung and pleura (tuberculosis, tumours, etc.).

Severe bleeding is usually due to injuries to the intercostal and internal thoracic arteries.

Haemothorax divides into mild, moderate and severe (total).

In mild cases, blood is accumulated only in the pleural sinuses of the pleural cavity; in moderate cases, its level can reach the scapular angles; and in severe haemothorax the pleural cavity is completely filled with blood. Owing to the anticoagulant properties the blood that has accumulated in the pleural cavity is not generally inclined to clotting, except for the catastrophic bleeding.

The clinical features of haemothorax depend on the intensity of bleeding, pressure on and displacement of the lung and mediastinum.

In severe cases, the clinical picture involves chest pain, restlessness, skin pallor and cyanosis, dyspnoea, cough (occasionally with blood, which is referred to as haemoptysis), dull percussion note, an increase in vocal fremitus, mute breath sounds, fast pulse and low blood pressure. The degree of anaemia depends on the amount of the blood loss. The aseptic inflammation of the pleura (haemopleuritis)causes an accumulation of serous fluid in the pleural cavity. Bacterial contamination of the site of haemothorax resulting from a damage to the bronchus or lung leads to purulent pleuritis, a very severe complication. To verify the diagnosis of haemothorax X-ray investigation and thoracentesis are used. Therapeutic thoracentesis will suffice for mild or moderate haemothorax, whereas total or massive haemothorax usually requires emergency thoracotomy with ligation of the bleeding vessels or the suturing of the lung rupture.

Haemopericardium, or an accumulation of blood into the pericardial sac, is most commonly caused by rupture of a diseased heart muscle or the ascending aorta and rarely by penetrating (e.g. stab) wounds or myocardial abscess, etc. As much as 200 ml of blood accumulated in the pericardial sac are unlikely to be critical; in contrast, 400-500 ml of blood contained in the pericardium may be life-threatening. Typically, the clinical symptoms and signs include restlessness, chest pains, dyspnoea, tachycardia, weak and fast pulse, low blood pressure, displaced or diminished heartbeat, widened cardiac borders, muffled heart sounds. The progression of the condition may result in cardiac packade, a dramatic complication. Pericardiocentesis is indicated for all cases suspicious of haemopericardium. Small amounts of blood found obviate radical methods of treatment (bed rest and cold compress will suffice), while massive haemopericardium requires an emergency operation to control the bleeding.

Intracranial haemorrhage (i.e. an accumulation of blood within the skull) frequently results from trauma and produces generalised and focal neurologic signs.

Haemarthrosis, or an extravasation of blood into a joint, is caused by an open or closed injury to the joint (fractures, dislocations etc.), in haemophilia, scurvy and some other diseases. Massive haemarthrosis restricts movements, levels its contours and leads to fluctuation, in knee joint involvement it produces patellar ballottement (or floating patella). To verify the diagnosis and rule out a fracture, X-ray films are obtained. In this case arthrocentesis is both of diagnostic and therapeutic value.

An accumulation of blood within tissues causes haematoma, a swelling composed of blood, which can be significant clinically (e.g. in femoral shaft fractures the volume of the blood accumulated can be as high as 500 ml). The most dangerous haematomas commonly result from the damage to the major blood vessels. The haematoma connected to an arterial lumen becomes a pulsating one, which subsequently forms a capsule and thus becomes pseudo-aneurysm (a «false» aneurysm). Apart from the general signs of acute anaemia, a pulsating haematoma has two main characteristics: (1) the pulsation over the swelling is synchronous with the pulse rhythm and (2) the presence of a blowing systolic murmur on auscultation. When a major vessel is damaged the affected limb becomes ischaemic, pale and cold on touch, its sensation is impaired, and the distal pulses are not palpable. This serves as an absolute indication for an emergent surgery to restore blood supply to the limb, which may help to save it.

The other type of evtravasation into tissues occurs when the tissue gets soaked or impregnated with small amounts of blood and is termed apoplexy.

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